Journal Article > Study

This study updates the previously described progress of patient safety efforts at Johns Hopkins Hospital. In 2012, hospital leaders declared their goal of exceeding The Joint Commission Top Performer award thresholds by achieving at least 96% compliance on accountability measures. The program included creating a robust quality management infrastructure through the Armstrong Institute, engaging frontline clinicians in peer learning communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving metrics. This study describes how the hospital was able to sustain performance on all of the accountability measures through 2014. The authors attribute their continued success to establishing an enduring quality management infrastructure, a project management office, and a formal accountability framework. This model highlights the degree of organization required to create lasting changes that improve patient safety across health systems.

Tools/Toolkit > Fact Sheet/FAQs

Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.

Tools/Toolkit > Government Resource

The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.

Journal Article > Commentary

Poison control centers serve as data collection points for ambulatory medication errors that result in harm. This commentary highlights how reporting programs that collect such data can collaborate and disseminate information about medication-related incidents to reduce errors and promote improvement.

This before-and-after study examined the impact of a patient safety project which included simulation training, teamwork training, and patient safety educational conferences. The authors found a decrease in hospital-acquired complications, better nurse perceptions of safety culture, and an improved observed-to-expected mortality ratio. These promising preliminary results should spur larger studies of these organizational safety efforts.

Journal Article > Study

A comprehensive obstetric patient safety program at an academic hospital—which involved teamwork training, standardizing care protocols, and establishing a robust quality assurance mechanism (including a dedicated patient safety nurse and an anonymous error reporting system)—has previously been shown to decrease adverse events and improve safety culture. This follow-up study demonstrates that the program was also associated with a reduction in malpractice claims and total payments over a 5-year period. The relationship between patient safety and malpractice claims is complex, as claims data likely do not correlate with overall safety. However, the results of this study, along with other studies showing that full disclosure of adverse events can reduce malpractice claims, lends support to the belief that improving safety culture can have downstream effects on malpractice lawsuits at the health-system level.

Book/Report

This white paper encourages hospitals to proactively develop and integrate a clinical crisis management plan into their organizational structure. It emphasizes the importance of full disclosure of adverse events, the role of leadership in developing a culture of safety, and the need for organizations to have a comprehensive crisis plan in place rather than reacting after events have occurred. The article provides a checklist and work plan for organizations to use in developing their plan, emphasizing that while their primary responsibility is to the patient and family, they should not neglect the second victims of adverse events—the frontline clinicians involved in the error.

Journal Article > Commentary

The ability to measure and track progress in patient safety remains an ongoing challenge, particularly at the organizational level. While efforts to improve safety culture and reduce specific preventable adverse events continue to grow, there is a paucity of literature on the human resources required to accomplish such goals. In this commentary, Dr. Peter Pronovost and colleagues describe the sequential investments made in human capital starting from the time of a highly publicized error at their institution through more recent times. They discuss the infrastructure developed at the patient care, unit or team, and organizational levels with specific roles, job descriptions, and percentage support outlined. They reflect upon their experiences and advocate for an equal commitment to investing in safety infrastructure through adequate staffing and training of leaders and change agents.

This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.

Journal Article > Commentary

Substantial progress has been made in improving health care safety, but more work is needed to optimize those efforts. Advocating for the development of an infrastructure that supports safety improvement, this editorial suggests that performance measures, initiative coordination, and recognition of local successes are ways to advance patient safety.

Journal Article > Study

As a result of the landmark Keystone ICU project, central line–associated bloodstream infections (CLABSIs) have emerged as a flagship patient safety target in recent years. The national Comprehensive Unit-Based Safety Program (CUSP) initiative aims to further disseminate these results by creating state-level cohort collaboratives. This current report of the initiative's implementation and sustainability in Hawaii continues the project's encouraging results, with CLABSI rates significantly decreased across the entire state. Most notably, Hawaii has successfully spread this program beyond adult intensive care units (ICUs) into pediatric and neonatal ICUs, and even non-ICU wards. The article outlines specific innovative tools and strategies utilized by the Hawaii collaborative, with an emphasis on cultural change and establishing new local norms. An AHRQ-sponsored CUSP toolkit is freely available.

A multifaceted program designed to optimize care of trauma patients resulted in a sustained improvement in trauma mortality over a 5-year period in this single-institution study. Part of the intervention included successful efforts to reduce health care–associated infections.